485 Madison Avenue Suite 202 New York, NY 10022 Phone - 212-747-1000 Fax 212-867-3371 CREDENTIALING CHECKLIST Primary Facility Name: Physician Name: (Please duplicate this page for every physician to be credentialed) FACILITY INFORMATION Facility application completed in its entirety and signed/dated by Authorized signatory Copy of all current facility licenses/certifications for each site W-9 Form Copy of Organization s Commercial General Liability Insurance and Professional Liability Insurance Face Sheets covering all sites All current equipment ACR, FDA, JCAHO or Other Accreditation Certificates by site, as applicable PLEASE SUBMIT APPLICATION AND ALL SUPPORTING DOCUMENTS TO: Care to Care 485 Madison Avenue Suite 202 New York, NY 10022 Attn: Credentialing Department Phone #: (888) 836-3899 Fax #: (212) 867-3371 Email: credentialing@caretocare.com 1 of 9
CORPORATE ORGANIZATION INFORMATION Please complete only if different from the individual facility. Corporation Name (As Filed With The IRS): DBA: Corporate Federal Tax ID#: Corporate Address: Corporate Zip Code: Corporate County: Corporate Telephone #: Corporate Fax #: Corporate Office Contact Name & Title: Corporate Contact E-Mail Address: BILLING/REMITTANCE INFORMATION If billing/remittance address and contact information is different from above, please complete the following: Billing Company Name: Address, State Zip: Telephone #: Fax #: Contact Name & Title: Contact Telephone #: Contact Fax #: CORRESPONDENCE LOCATION INFORMATION Location Name: Complete Address: Telephone #: Fax #: Credentialing Contact: Credentialing Contact Telephone #: Credentialing Contact Fax #: Credentialing Contact E-Mail Address: 2 of 9
(This part must be completed for each facility location. Please make additional copies as needed for each facility location) Facility Name: Address & Zip Code: County: Telephone #: Fax #: Areas Served By Facility: (County/Zip Codes) Facility Medicare #: Facility Medicaid #: Facility NPI #: Facility Tax ID # FACILITY INFORMATION (as you would like it to appear in a directory) FACILITY CONTACT INFORMATION Facility Scheduling Contact Name and Title: Facility Scheduling Contact Phone #: Facility Scheduling Fax #: Contact E-mail Address: Medical Director: Website: TYPE OF FACILITY Free Standing Imaging Facility Physician s Office Hospital-Based Facility Mobile Services Unit Other FACILITY LICENSURE Is your facility licensed by the state? N/A If yes, please give the following information for each license type: Facility Licensure/Certification (Attach copies of all licensures and certificates) State Type of License License Number Expiration Date 3 of 9
FACILITY INFORMATION Hours of Operation: Monday Tuesday Wednesday Thursday Friday Saturday Sunday What is the average waiting time (days) to obtain a routine appointment in your office? CT MR PET Screening Mammo What is the average waiting time to obtain an urgent appointment? CT MR PET Diagnostic Mammo Do you offer sedation? Do you accept worker s compensation cases? Handicapped accessible? Hearing impaired accommodations? (TTY/TDD) Hearing impaired accommodations? (ASL) Languages spoken by staff at this location: FACILITY INSURANCE Please complete the information below with the liability insurance information for the facility. (Attach copies of all policy certificates.) Type Of Insurance General Liability Insurance Professional Liability Insurance Facility Other Liability Insurance Carrier Name Policy Number Policy Terms From To Date Date Limits of Liability Occurrence Aggregate FACILITY EQUIPMENT Equipment Summary: Please check all services you provide at your facility and complete all equipment specifications. Services Facility Provides: (Check all that apply) CT Fluoroscopy Echocardiography EMG IVP EKG MRI Mammography Holter Monitoring Myelography Ultrasound MRA PET X-ray Nuclear Cardiography Arthrography CTA Nuclear Medicine Bone Densitometry Doppler Studies Other Breast MRI & MR Guided PET-CT CCTA Breast Biopsy Low Dose CT 4 of 9
Equipment Specifications: If more than one unit for any above modality, please add and number each piece of equipment. (Attach copies of current accreditation certificates.) MRI Manufacturer /Model: Table weight Limits: ACR Accreditation #: Coils: Year manufactured: Software: Choose one: Open Close Date of last upgrade: Field strength: Do you perform MRA? Mobile Unit Only? COMPUTERIZED TOMOGRAPHY (CT) Manufacturer /Model: ACR Accreditation #: Year manufactured: Mobile Unit Only? Do you perform CTA? If yes: CTA of Lower Extremities or Coronary CTA Slices per Rotation: Date of last upgrade: MAMMOGRAPHY ACR Accreditation #: Date of last upgrade: FDA Accreditation # Mobile Unit Only? ULTRASOUND Transducers: ACR Accreditation #: Date of last upgrade: Mobile Unit Only? 5 of 9
NUCLEAR MEDICINE ACR or ICANL Accreditation #: Is this equipment utilized primarily for cardiac nuclear imaging? Current NRC License #: Current State Materials License #: Date of Last Upgrade: SPECT Capable If, # of Heads: Mobile Unit Only? RADIOLOGRAPHY/FLUOROSCOPY Date of Last Upgrade: Mobile Unit Only? PET OR PET-CT Scanner Type: Date of Last Upgrade: ACR Accreditation #: Mobile Unit Only? BONE DENSITOMETRY Date of Last Upgrade: DEXA? Fan Beam? 6 of 9
DECLARATION OF FACILITY AND NON-PHYSICIAN PROFESSIONAL INFORMATION (Please complete one for each facility location.) Primary Facility Name: Primary Facility Address: 1) Have there ever been, or are there currently, any claims, settlements, or judgments against your Facility, even if not resulting in monetary damages, or have you received any notice of "Intent to File"? If yes, attach explanation. 2) Has your facility ever had any general or professional liability insurance coverage canceled, declined or modified (i.e. reduced limits, restricted coverage), or has any renewal ever been refused, or has your facility voluntarily given up coverage? If yes, attach explanation. 3) Has your facility ever been denied membership or renewal of membership, or been subject to any disciplinary action in any hospital, IPA, HMO, PHO, PPO, managed care organization, with the exception of no network need or professional society, or is such action pending? If yes, attach explanation. 4) Has any Professional Conduct Board or any State Board of Medical Examiners disciplined any of your facility staff or has any Staff member been reprimanded, or disciplined by any state or federal agency that disciplines physicians or allied health professionals? If yes, attach explanation. 5) Has your facility ever been reprimanded, censured, excluded, suspended, or disqualified from Federal or State Programs? If yes, attach explanation. 6) Has your facility state license ever been revoked, suspended, or subject to probation or any conditions or limitations in any state? If yes, attach explanation. 7) Have any of your licensed non-physician professional staff licenses ever been revoked, suspended, or subject to probation or any conditions or limitations in any state? If yes, attach explanation. 7 of 9
FACILITY ATTESTATION I (name) on behalf of (primary facility name), hereinafter Facility, hereby authorize Care to Care, IPA, LLC and its agencies to consult with administrators and members of medical staffs of hospitals, facilities, malpractice carriers and organizations with which Facility or its licensed professional staff has been associated, who may have bearing on the Facility s qualifications. Facility further consents to inspection of all records and documents that may be material to facility s evaluation. Facility agrees to abide by the terms of the Agreement with Care to Care, IPA,LLC, as well as the policies that may be adopted by Care to Care, IPA, LLC concerning the conditions, criteria, and standards of participation in the provider panel. Facility shall provide immediate notice to Care to Care, IPA, LLC of any circumstance that limits any of the facility s ability to provide the Radiological services as outlined in the application. All physicians providing services at facility are duly licensed in the state in which they practice, and are Board Certified or eligible to sit for board certification in their specialty. All technologists and other nonphysician medical personnel are duly licensed and/or certified. As employer of Facility non-physician staff, I confirm that none of my employed professionals have been sanctioned by State or Federal Licensing authorities and that no employees of Facility have a criminal background. By the signature below I hereby attest that all information contained herein is complete and accurate, and I agree to provide information as requested to support this application. X Medical Director or Facility Administrator Print Name/Title Date 8 of 9
Primary Facility Name: ROSTER INFORMATION Please list all physicians rendering services at this location. 1. Medical Director 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. If the physician is practicing at multiple locations, please provide a roster of all locations with the physician s respective effective date. What professional training and experience requirements must a physician meet to practice at your facility? 9 of 9